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quality standards. The specific problem is: citations need to follow WP:MEDRS- some are incomplete, out-of-date or unreliable sources. Please help improve this article if you can. (December 2012) Separation anxiety disorder Classification and external resources ICD-10 ICD-9 DiseasesDB eMedicine MeSH F93.0 309.21 34361 article/916737 D001010

Separation anxiety disorder (SAD) is a psychological condition in which an individual experiences excessive anxiety regarding separation from home or from people to whom the individual has a strong emotional attachment (e.g. a parent, grandparents, or siblings). According to the American Psychology Association, separation anxiety disorder is the inappropriate and excessive display of fear and distress when faced with situations of separation from the home or from a specific attachment figure. The anxiety that is expressed is categorized as being atypical of the expected developmental level and age.[dead link][1] The severity of the symptoms ranges from anticipatory uneasiness to full-blown anxiety about separation.[2] SAD may cause significant negative effects within a child's everyday life, as well. These effects can be seen in areas of social and emotional functioning, family life, physical health, and within the academic context.[dead link][1] The duration of this problem must persist for at least four weeks and must present itself before a child is 18 years of age to be diagnosed as SAD, as specified by the DSM-IV.[3] Contents [hide] 1 Prevalence 2 Classification 3 Symptoms 4 Neural correlates 5 Contributing factors/etiology 6 SAD in the academic setting 7 Criteria for diagnosis 8 Assessment methods and tools o 8.1 Diagnostic interviews o 8.2 Self-report measures o 8.3 Observation

8.4 Assessment of preschool-aged children 9 Treatment o 9.1 Non-pharmacological 9.1.1 Behavioral therapy 9.1.2 Contingency management 9.1.3 Cognitive behavioral therapy (CBT) o 9.2 Pharmacological 10 Prognosis 11 Longitudinal effects of SAD 12 In other animals 13 See also 14 References 15 External links

[edit]Prevalence Anxiety disorders are the most common type of psychopathology to occur in today's youth, affecting from 5 25% of children world-wide.[1] Of these anxiety disorders, SAD accounts for a large proportion of diagnoses. SAD may account for up to 50% of the anxiety disorders as recorded in referrals for mental health treatment.[1] SAD is noted as one of the earliest-occurring of all anxiety disorders.[3] Adult separation anxiety disorder affects roughly 7% of adults. Research suggests that 4.1% of children will experience a clinical level of separation anxiety. Of that 4.1% it is calculated that nearly a third of all cases will persist into adulthood if left untreated.[1]Research continues to explore the implications that early dispositions of SAD in childhood may serve as risk factors for the development of mental disorders throughout adolescence and adulthood.[4] It is presumed that a much higher percentage of children suffer from a small amount of separation anxiety, and are not actually diagnosed. Multiple studies have found higher rates of SAD in girls than in boys, and that paternal absence may increase the chances of SAD in girls.[5] [edit]Classification Separation anxiety disorder should not be confused with separation anxiety, which occurs as "a normal stage of development for healthy, secure babies."[6] Separation anxiety occurs as babies begin to understand their own selfhoodor understand that they are a separate person from their primary caregiver. At the same time, the concept of object permanence emergeswhich is when children learn that something still exists when it is not seen or heard. As babies begin to understand that they can be separated from their primary caregiver, they do not understand that their caregiver will return, nor do they have a concept of time. [edit]Symptoms Symptoms may vary in how children exhibit them, in what context, and the severity. Some common symptoms that children with SAD display include: Significant distress, worry, and fear at the thought of or event of separation; Clinging to the parent, crying, throwing tantrums, and refusing to participate in activities that require separation from the attachment figure.[1] Fear of harm coming to the attachment figure or the self when separated if they are separated [7] Difficulties sleeping without the attachment figure present; persistent nightmares

Somatic symptoms including complaints of stomachaches, nausea, or headaches, which, may or may not actually be occurring [7] Avoidance, refusal, reluctance and oppositional behaviors in attempt to prevent separation from occurring [8] [edit]Neural correlates Preliminary evidence shows that heightened activity of the amygdala is associated with symptoms of separation anxiety disorder. Defects in the ventrolateral and dorsomedial areas of the prefrontal cortex are also correlated to anxiety disorders in children.[9] [edit]Contributing factors/etiology Factors that contribute to the disorder include a combination and interaction of biological, cognitive, genetic, environmental, child temperament and behavioral factors. Commonly-noted environmental factors include parenting behavior. Examples of parenting behavior as contributing factors may include: 1. Low parental warmth, discouraging autonomy in child 2. Attachment relationships with parents or caregiver insecure or anxious attachment styles have been shown to produce feelings of vulnerability, fear of being alone, and chronic anxiety 3. Locus of control this phenomena revolves around a child's thoughts and ability to control one's own environment 4. Overprotective or intrusive parenting behaviors this parenting style may discourage a child's independence and further enforce parental dependence [1] A child's temperament can also impact the development of SAD. Timid and shy behaviors may be referred to as "behaviorally inhibited temperaments" in which the child may experience anxiety when they are not familiar with a particular location or person.[7] [edit]SAD in the academic setting As with other anxiety disorders, children with SAD face more obstacles at school than those without anxiety disorders. Adjustment and relating school functioning have been found to be much more difficult for anxious children.[10] In some severe forms of SAD, children may act disruptively in class or may refuse to attend school all together. It is estimated that nearly 75% of children with SAD exhibit some form of school refusal behavior.[1] This is a serious problem because, as children fall further behind in coursework, it becomes increasingly difficult for them to return to school.[11] Short-term problems resulting from academic refusal include poor academic performance or decline in performance, alienation from peers, and conflict within the family.[1] [edit]Criteria for diagnosis Separation anxiety occurs in many infants and young children as they are becoming acclimated with their surroundings. This anxiety is viewed as a normal developmental phase between the months of early infancy until age two.[1] Other sources note that a definite diagnosis of SAD should not be presented until after the age of three.[7] Separation anxiety may be diagnosed as a disorder if the child's anxiety related to separation from the home or attachment figure is deemed excessive; if the level of anxiety surpasses that of the acceptable caliber for the child's developmental level and age; and if the anxiety negatively impacts the child's everyday life.[1] A very important part of diagnosing SAD involves fully understanding the symptoms as the child exhibits them. A clinician must note how behaviors are displayed, the duration that they have persisted, the context in which

they occur, and the severity of the symptoms.[7] It is also important to understand the possible contributing factors. [edit]Assessment methods and tools Assessment methods include diagnostic interviews, self-report measures from both the parent and child, observation of parent-child interaction, and specialized assessment for preschool-aged children. It is vital to explore and understand various facets of the child's development including social life, feeding and sleep schedules, any medical issues, traumatic events experienced, family history of mental or anxiety health issues. The compilation of aspects of a child's life aids in capturing a multi-dimensional view of the child's life.[7] [edit]Diagnostic interviews Clinicians may utilize interviews as an assessment tool to gauge the symptomatic occurrences to aid in diagnosing SAD. Interviews may be conducted with the child and also with the attachment figure. Interviewing both child and parent separately allows for the clinician to compile different points of view and information.[1] Commonly used interviews include:[1] Anxiety Disorders Interview Schedule for the DSM-IV, Child Parent Versions (ADIS-IV-C/P) Diagnostic Interview Schedule for Children, Version IV (DISC-IV) Schedule for Affective Disorders and Schizophrenia for School-aged Children-Present and lifetime version (K-SADS-IV) [edit]Self-report measures This form of assessment should not be the sole basis of a SAD diagnosis. It is also important to verify that the child whom is reporting on their experiences has the cognitive and communication skills appropriate to accurately comprehend and respond to these measurements.[1] [edit]Observation As noted by Altman, McGoey & Sommer, it is important to observe the child, "in multiple contexts, on numerous occasions, and in their everyday environments (home, daycare, preschool)".[7] It is beneficial to view parent and child interactions and behaviors that may contribute to SAD.[1] Dyadic Parent-Child Interaction Coding System and recently the Dyadic Parent-Child Interaction Coding System II (DPICS II) are methods used when observing parents and children interactions. [edit]Assessment of preschool-aged children At the preschool-aged stage, early identification and intervention is crucial.[1] There is much more that needs to be done in regards to creating age-appropriate assessments for younger children. It is important to take into consideration the writing and communication abilities of these younger children.[7] A commonly-used assessment tool for preschool-aged children (ages 25) is the Preschool Age Psychiatric Assessment (PAPA).[1] Additional questionnaires and rating scales that are used to assess the younger population include the Achenbach Scales, the Fear Survey Schedule for Infants and Preschoolers, and The InfantPreschool Scale for Inhibited Behaviors.[7] Behavioral observations are also utilized when assessing the younger population. Observations enable the clinician to view some of the behaviors and emotions in specific contexts.[7] [edit]Treatment [edit]Non-pharmacological Non-pharmacological treatments are methods of treatment that do not involve drugs. Non-pharmacological treatments are to be used before using pharmacological treatments.[1] [edit]Behavioral therapy

Behavioral therapies are types of non-pharmacological treatment which are mainly exposure-based techniques. These include techniques such as systematic desensitization, emotive imagery, participant modelling and contingency management. Children are forced to go to school and eventually show decreasing symptoms of SAD.[2] [edit]Contingency management Contingency management is a form of treatment found to be effective for younger children with SAD. Contingency management revolves around a reward system with verbal or tangible reinforcement. When children undergoing contingency management show signs of independence, they are praised or given a reward. Children in preschool who show symptoms of SAD do not have the communicative ability to express their emotions or the self-control ability to cope with their separation anxiety on their own, so parental involvement is crucial in younger cases of SAD.[2] [edit]Cognitive behavioral therapy (CBT) Cognitive behavioral therapy focuses on helping children with SAD reduce feelings of anxiety through practices of exposure to anxiety-inducing situations and active metacognition to reduce anxious thoughts.[1] According to Kendall and colleagues, there are four components which must be taught to a child undergoing CBT:[12] 1. Recognizing anxious feelings and behaviors 2. Discussing situations that provoke anxious behaviors 3. Developing a coping plan with appropriate reactions to situations 4. Evaluating effectiveness of the coping plan The method behind CBT is that faulty cognition is the reason for the anxiety of SAD.[12] A 1998 study of CBT on children nine and younger found 64% of the treated children did not meet the DSM's criteria for SAD. Only 5% of the waitlisted children in the study showed these results.[12] Another study investigated the content of thoughts in anxious children who suffered from separation anxiety as well as from social phobia and/or generalizable anxiety. The results added to knowledge of cognitive behavioral therapy. It is suggested that cognitive therapy for children suffering from separation anxiety (along with social phobia and generalized anxiety) should be aimed at identifying negative cognitions of one's own behavior in the threat of anxiety-evoking situations and to modify these thoughts to promote self-esteem and ability to properly cope with the given situation.[8] Cognitive procedures are a form of treatment found to be ideal for older children with SAD. [2] The theory behind this technique is that the child's dysfunctional thoughts, attitudes, and beliefs are what lead to anxiety and cause anxious behavior.[2] Children who are being treated with cognitive procedures are taught to ask themselves if there is "evidence" to support their anxious thoughts and behaviors.[2] They are taught "coping thoughts" to use during anxiety-inducing situations and to praise themselves for handling the situation bravely.[2] [edit]Pharmacological Pharmacological treatment is used in extreme cases of SAD when non-pharmacological treatments fail,[2][12] typically for school refusal. However, children with school refusal may have conditions other than SAD. Pharmacological management of SAD includes the use of selective serotonin reuptake inhibitors.[2] [edit]Prognosis Helping children with separation anxiety to identify the circumstances that elicit their anxiety (upcoming separation events) is important. A child's ability to tolerate separations should gradually increase over time

when he or she is gradually exposed to the feared events. Encouraging a child with separation anxiety disorder to feel competent and empowered, as well as to discuss feelings associated with anxiety-provoking events promotes recovery. Children with separation anxiety disorder often respond negatively to perceived anxiety in their caretakers, in that parents and caregivers who also have anxiety disorders may unwittingly confirm a child's unrealistic fears that something terrible may happen if they are separated from each other. Thus, it is critical that parents and caretakers become aware of their own feelings and communicate a sense of safety and confidence about separation.[13] [edit]Longitudinal effects of SAD Several studies aim to understand the long-term mental health consequences of SAD.[4] SAD contributed to vulnerability and acted as a strong risk factor for developing mental disorders in people aged 1930. Specifically disorders including panic disorder and depressive disorders were more likely to occur.[4] Other sources also support the increased likelihood of displaying either of the two psychopathologies with previous history of childhood SAD.[3]

Part 2 Diagnostic Features:

Separation Anxiety Disorder is diagnosed when fear of separation constitutes the focus of the anxiety and when such anxiety first arose during the early years of childhood. It is differentiated from normal separation anxiety when it is of a degree (severity) that is statistically unusual (including an abnormal persistence beyond the usual age period), and when it is associated with significant problems in social functioning. Complications: The severity of symptomatology ranges from anticipatory uneasiness to full-blown anxiety about separation, but children are usually brought to the clinician when SAD results in school refusal or somatic symptoms. School refusal is reported in about 75% of children with SAD, and SAD is reported to occur in up to 80% of children with school refusal. Comorbidity: Longitudinal studies have found that children with this disorder are more likely to develop other anxiety disorders in adulthood (i.e., specific phobia, obsessive compulsive disorder, posttraumatic stress disorder, and acute stress disorder). Associated No laboratory test has been Laboratory found to be diagnostic of this Findings: disorder.

Prevalence: Different epidemiological studies indicate a prevalence of 4 to 5% in children and adolescents. In contrast to other anxiety disorders, 50 to 75% of children with SAD come from homes of low socioeconomic status. Treatment: First choice treatment for this disorder is cognitive behavioral therapy (CBT), and most (76%) children with this disorder respond to this treatment. Should CBT fail; treatment with selective serotonin reuptake inhibitors (SSRI) antidepressant medication is often effective. Treatment with tricyclic antidepressant medication or benzodiazepine antianxiety medication has been proven no more effective than placebo.

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Phobias Slideshow Pictures Take the Panic Attacks Quiz! Generalized Anxiety Disorder (GAD) Slideshow Pictures Medical Author: Roxanne Dryden-Edwards, MD Medical Editor: Melissa Conrad Stppler, MD What is separation anxiety disorder? What are the symptoms and signs of separation anxiety disorder? What are causes and risk factors for separation anxiety disorder? How is separation anxiety disorder diagnosed? What is the treatment for separation anxiety disorder?

What happens if separation anxiety disorder is left untreated? Where can I find more information on separation anxiety disorder? Separation Anxiety Disorder At A Glance Patient Comments: Separation Anxiety - Cause Patient Comments: Separation Anxiety - Symptoms

Part3 What is separation anxiety disorder? To understand separation anxiety disorder, it is important to first recognize the normal difficulty that infants and toddlers have with strangers and in separating from parents and caretakers. Infants show stranger anxiety by crying when someone unfamiliar to them approaches. This normal stage of development is connected with the baby learning to distinguish his or her parents or other familiar caretakers from people they don't know. Stranger anxiety usually starts at about 8 months of age and ends by 2 years of age, according to the American Academy of Pediatrics. Separation anxiety as a normal life stage first develops at about 7 months of age, once a baby understands that his or her caregivers do not disappear when out of sight (object permanence). That leads to the baby developing a true attachment to those adults. Normal separation anxiety is most commonly at its strongest at 10-18 months of age and gradually subsides, usually by 3 years of age. Normal separation anxiety may result in parents having trouble with their babies at bedtime or other times of separation, in that the child becomes anxious, cries, or clings to the caretaker. In addition to the child's temperament, factors that contribute to how quickly or successfully he or she moves past separation anxiety by preschool age include how well the parent and child reunite, the skills the child and adult have at coping with the separation, and how well the adult responds to the infant's separation issues. For example, children of anxious parents tend to be anxious children. Separation anxiety disorder is a mental health disorder that begins in childhood and is characterized by worrying that is out of proportion to the situation of temporarily leaving home or otherwise separating from loved ones. Approximately 4%-5% of children and adolescents suffer from separation anxiety disorder.